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The missing member

A strange case of mistaken identity was reported in the Berliner klinische Wochenschrift in 1874, and subsequently translated in the Medical Herald. It was given this striking headline:

W. K., a strongly-built farmer, aged 57, was injured on the 25th of October, 1867, by falling from his wagon. As he got up, the horse forced him against a tree, and the hind wheel of the wagon passed close in front of his body, and he found that he was severely hurt.

‘Close in front of his body’ is not entirely accurate, since it is evident that the wheel passed over some important parts of his anatomy.

Upon examination, it was found that the scrotum and penis were covered with blood, and that the scrotum was much swollen and filled with extravasated [escaped] blood. There was no fracture of the bones of the pelvis, and no injury of the abdominal organs could be found.

That’s something, at least. But the existing injuries were far from trivial.

The penis, however, was much injured; the glans could not be recognized, and the whole organ hung soft and flaccid as if it had been completely crushed, but it was not very painful upon manual examination.

The farmer sought medical attention, naturally enough. The doctor attempted to pass a catheter into his urethra to see how bad the damage was, but did not succeed: there was some obstruction blocking the vessel.

The patient was placed in bed, and compresses, soaked in lead-water applied to the injured parts. During the night no urine passed from the penis, but it was found that there had been extravasion of that fluid into the scrotum, which was much distended and emitted a urinous odour.

A most unfortunate complication. The impact of the wheel against the man’s abdomen had evidently severed the urethra; urine was now unable to escape via the usual route and was instead collecting inside the scrotum.

As it was now evident that some operative interference was necessary, the patient was placed under the influence of chloroform, a catheter introduced as far as possible into the urethra, and an incision made down upon it through the raphe of the scrotum.

The ‘raphe’ is the ridge on the midline of the scrotum.

The tissues were now dissected away, layer by layer, and careful search made for the urethra, in which the catheter was supposed to lie; but that passage could not be found, and, owing to an attack of hemorrhage of a violent character, further investigation had to be desisted from.

The patient was comfortable that evening, and urine escaped freely through the surgical wound in the scrotum.

On the 30th of October a new effort was made to find the urethra. The first incision was continued up to the root of the penis, and there was found to be beneath the symphysis a cavity filled with ragged tissues and granulations, into which an elastic catheter was thrust to the extent of an inch or two, but no further introduction of the instrument was possible.

The symphysis is a cartilaginous joint between the bones of the pubis. This second operation was no more conclusive than the first. A week later an abscess formed in the wall of the abdomen, and the doctor realised that the patient’s injury could not simply be left to heal.

A catheter was introduced into the superior opening, which passed down to the opening under the symphysis; and on the 12th an incision was made in the inguinal region, and the penis, deprived of its skin, but in other respects uninjured, was found lying imbedded in the fat and connective tissue covering the muscles of the abdomen.

Yes, that’s right: the doctor found the patient’s penis embedded in the abdominal wall. What had happened? It appears that the farmer had suffered a nasty degloving injury: the wheel of his waggon had torn the skin off the penis, leaving nothing but a tube of skin hanging down. This the doctor had originally mistaken for a badly damaged penis; but the main substance of the organ – the erectile tissue and urethra – had actually slipped up into the lower abdomen and disappeared from view.

The glans and prepuce were dissected off, but, at the request of the patient, who stated that he only wished the penis for the function of urination, no further attempt was made to restore the organ to its normal state.

Not all patients would be quite as sanguine about this outcome.

The wound finally healed, the penis up to the glans being adherent to the muscular structure of the part and covered with skin. The glans itself was left bare and movable, so that the patient can urinate with no trouble. Erections occur from time to time, but are attended with no pain, and the man is very unwilling to have any further operative measures undertaken.

Probably for the best. Plastic surgery was very much in its infancy in the 1860s, and there’s no knowing what another operation might have done to his damaged appendage.